Not Just Waitin’ on Our Prostates to Change

Not Just Waitin’ on Our Prostates to Change

The big medical news of this past week was a seminal study of prostate cancer, suggesting that when it is diagnosed, we men have options-including the option of waiting. In the words of the study authors themselves: “At a median of 10 years, prostate-cancer–specific mortality was low irrespective of the treatment assigned, with no significant difference among treatments.” The treatments studied included surgery right away, radiation right away, or monitoring- with treatment deferred until or unless the disease progressed.

The disease progressed significantly more often among the men randomly assigned to monitoring, but that is hardly a surprise. The very point of immediate treatment for localized prostate cancer is to nip the malady in the proverbial bud, and forestall progression. Catching and treating cancer early to address it before it is prone to progress is the basic goal of all screening efforts, from PSA to mammograms, Pap smears to colonoscopy.

Prostate cancer, however, is a notorious challenge in this regard. The prostate gland grows throughout a man’s life, causing almost all of us eventually to become nocturnally itinerant for the obvious reason (yes, I am there). The same factors that cause the gland to grow continuously make cancer all but inevitable. The best estimates indicate that 80% or more of men age 80 or older have prostate cancer.

However, most of these men die with prostate cancer, not of it. More often than not, the disease is quite indolent, progressing slowly if at all. Just that was seen in the new study. Of the 545 men randomly assigned to monitoring, disease progression occurred eventually in 112, or 20%, at a rate of 22.9 events per thousand person-years of monitoring (in case it’s not clear, a ‘person-year’ of monitoring is the observation of one person for a full year).  Flipped around, this means that in 80% of men not treated for their localized prostate cancer, the disease did not appreciably progress over ten years.

Still, that low rate of progression was higher than in the groups getting immediate treatment, which would seem to beg the question: why take the chance? But the answer here is a good one. Even in skilled hands, treatment of prostate cancer carries the risk of rather unpleasant side effects, from sexual dysfunction, to incontinence of bladder or even bowel. Skilled hands minimize these risks, and they are certainly worth taking when the disease itself is dangerous. But since the localized cancer so often just sits there and does no discernible harm itself, it argues against treatments more injurious than the disease. 

There are various challenges related to screening for prostate cancer, but this is the big one: we are not yet good at predicting which of the early cancers will ever progress. For this reason, the U.S. Preventive Services Task Force has historically recommended against prostate cancer screening, and for whatever it’s worth, this age-eligible Preventive Medicine specialist- has not undergone any. 

What I have done, however, is everything possible to reduce my chances of ever getting prostate cancer in the first place, at least until I am 80 or so; and to reduce the likelihood that if I do get prostate cancer, it will progress. What I have done is leverage lifestyle as preventive medicine.

The power of lifestyle as medicine, and perhaps especially preventive medicine, is nothing short of stunning. Fully 80% of our personal lifetime risk of any major chronic disease- heart disease, stroke, cancer, COPD, diabetes, dementia- and that much of the total, global burden of such diseases is preventable by means long accessible, using knowledge long at our disposal. As much as 60% of all cancer per se is thought to be preventable by avoiding tobacco, exercising routinely, eating optimally, maintaining a healthy weight, and avoiding behaviors that carry a high-risk of transmitting infection, from unprotected sex, to intravenous drug use.

That’s fairly compelling already, but the new study was about men already diagnosed with prostate cancer. At that point, hasn’t the window of opportunity for prevention closed? 

No, it has not. In one study published in 2008, Dean Ornish and colleagues showed that a lifestyle intervention in men with prostate cancer could activate cancer suppressor genes, and stifle the activity of cancer promoter genes. In a follow up paper five years later, they demonstrated the same intervention lengthens telomeres, caps at the ends of our chromosomes the length of which correlates strongly with the length of life itself.

At the height of our enthusiasm for genomics, we thought that DNA was destiny. When we learned that was wrong, we were at first disappointed. But we have since gone on to learn, in what we might call the epigenetic age, that gene expression can be altered dramatically by our lifestyle practices. The work of Ornish and others shows that DNA is only rarely destiny, while dinner is, routinely. We can nurture nature.

This of course relates back to the new study, and its implications. There may be no need for immediate treatment when localized prostate cancer is first diagnosed, whether as a result of screening or from the investigation of symptoms. There are pros and cons either way, but monitoring for progression, otherwise known as “watchful waiting,” is a valid option.

But from the realm of lifestyle medicine comes the crucial addendum: we can do much more than just keep on waiting on the status of our prostate cancer to change, and taking action when it does. Leveraging the power of a short list of lifestyle factors, we can change the behavior of our very genes- and reduce the risks of progression at their origins. Better still, we can adopt the same strategy before ever a cancer diagnosis is made, reduce the risk it ever will be, and perhaps avoid entirely the dilemma of a difficult treatment choice.

 

-fin

David L. Katz

Director, Yale University Prevention Research Center; Griffin Hospital

President, American College of Lifestyle Medicine

Senior Medical Advisor, Verywell.com

Founder, The True Health Initiative


Follow at: LinkedIN; Twitter; Facebook

Read at: INfluencer Blog; Huffington Post; US News & World Report; Verywell; Forbes

Sanjay Koul

Senior Consultant

3 年

Please save human lives

  • 该图片无替代文字
回复
Obiageli Nnodu

Professor of Haematology & Director at Centre of Excellence For Sickle Cell Disease Research & Training, (CESRTA) University of Abuja

8 年

David, this is succinct. Thanks.

Cathy Adamson

Cardiology Nurse Practitioner

8 年

This is an excellent article reviewing not only the current thoughts regarding prostrate health but also the personal health choices available to individuals.

回复
Raymond VanOcker

Nutrition & Health Coach at Renew Mind, Body, Spirit

8 年

Dr. Katz is a true leader in the field of Nutrition & Wellness.

回复

要查看或添加评论,请登录

David L. Katz, MD, MPH的更多文章

  • The Better Assessment of Dietary Intake, Now

    The Better Assessment of Dietary Intake, Now

    A recent article in Science, citing a recent study in Nature Food, contends that we need a new and better way to…

    7 条评论
  • Ultra-Processed Foods: My Verdict

    Ultra-Processed Foods: My Verdict

    Guilty, as charged, in case you are quite short on time. If you have a minute, or ten, by all means- please read on.

    15 条评论
  • Of Blue Zones and Bull…Dozers

    Of Blue Zones and Bull…Dozers

    Since first learning of the Blue Zones over a decade ago, I have held them up as the most luminous, decisive…

    17 条评论
  • Correlation Isn’t Causation, Except When It Is

    Correlation Isn’t Causation, Except When It Is

    In the world at large- a clickbait, deepfake, soundbite world- nuance is everywhere on the ropes. We seek our answers…

    11 条评论
  • Food as Medicine: The Case for Measuring What We Intend to Manage

    Food as Medicine: The Case for Measuring What We Intend to Manage

    The Food-as-Medicine movement - a movement I applaud, in which I am involved, and arguably to which my whole career has…

    11 条评论
  • Nutrition Research, Olive Oil, and The Case for More 'And,' Less 'Or'

    Nutrition Research, Olive Oil, and The Case for More 'And,' Less 'Or'

    After some 40 years devoted to the science (and art) of applying nutrition to the promotion of human health, I hold…

    16 条评论
  • The Many Flavors of Optimal Nutrition

    The Many Flavors of Optimal Nutrition

    Some years ago, I wrote a commissioned article for a peer-reviewed compendium, entitled “Can We Say What Diet is Best…

    5 条评论
  • An Anti-Diet Antidote

    An Anti-Diet Antidote

    The “anti-diet” movement, we are told- specifically by The Washington Post and The Examination- began with good…

    22 条评论
  • Food as Medicine, and the Pseudo-Sophistication of Doubt

    Food as Medicine, and the Pseudo-Sophistication of Doubt

    A colleague and I recently had the opportunity to “pitch” what we do, what our company offers, to a convened group of…

    13 条评论
  • Of Course, Food-as-Medicine Works

    Of Course, Food-as-Medicine Works

    Diet in America, and much of the world, is badly broken. How badly? Poor overall diet quality is the single leading…

    3 条评论

社区洞察

其他会员也浏览了